7 Things to Know About Preventing a Leading Cause of Death in the US
Overdose is classified by the Centers for Disease Control as a national epidemic, surpassing even motor vehicle accidents to become the leading cause of injury death in the U.S., with 41,340 overdose deaths in 2011. Each day, 113 people die from overdose in this country.
This mortality rate has increased 118 percent since 1999, escalating overdose to a national crisis. Of these deaths, 16,917 were related directly to opiate (opioid) pain medications, and many more were caused by other opiates, such as heroin, in combination with other classifications of substances such as benzodiazepines (anti-anxiety and sedative medications) and alcohol. In 2011 alone, approximately 1.4 million people were seen in emergency rooms for the misuse of pharmaceuticals.
Misusers of pharmaceuticals often visit multiple doctors in pursuit of of these medications for either personal use or distribution on the black market. Forty-nine states have enacted legislation to track and control prescription narcotics and to prevent the over-prescribing of these addictive drugs. Pharmaceutical companies have also attempted to decrease the misuse of opiate medications by developing formulations of opiates that prevent these pills from being crushed and liquified for intravenous use.
An unintended consequence of the efforts to stem the tide of pharmaceutical and opiate addiction has been a dramatic national increase in heroin use, which surely has added to the increasing rate of overdose deaths, since heroin is a fast-acting opiate and carries a high overdose risk, especially when administered intravenously.
In light of the overdose epidemic, many states are enacting legislation to make the overdose reversal agent naloxone, also known as Narcan, more widely available to those at risk of overdose.
Here are some important things many people might not know about naloxone and overdose prevention.
1. Naloxone is the only drug known to reverse opiate overdose.
Opiate overdose occurs when an opioid drug floods particular receptor sites in the brain called opioid receptors. When too many of these receptor sites are flooded, activity in the brain’s respiratory center slows, leading to a decreased breathing rate (respiratory depression) or a complete cessation of breathing altogether (respiratory arrest). Within minutes, an overdose can progress from respiratory depression to respiratory arrest, which can quickly progress to cardiac arrest and death.
Naloxone is a medication known as an overdose reversal agent, the only drug of its class for reversing the effects of an opiate overdose. Naloxone works by kicking opiates off the opioid receptors in the brain’s respiratory center and sitting in their place. This awakens the brain’s respiratory center and breathing is quickly restored, provided the person overdosing has not slipped into cardiac arrest, in which case naloxone is entirely ineffective and of no use.
Naloxone’s effects, although quick, are temporary. Overdose symptoms can return, especially when long-acting opiates such as methadone are involved, and repeated doses of naloxone may be necessary. People recovering from an overdose must be closely monitored.
2. Naloxone has been used for decades as an overdose reversal agent.
The quick administration of naloxone at the onset of an opiate overdose is key. Police or EMTs may not arrive on scene in time to administer naloxone before an overdose has progressed to cardiac arrest. The effort toward wider distribution of naloxone seeks to make this overdose reversal agent available when and where it is needed the most—at the onset of an overdose.
Naloxone has been in use since 1971 in hospital and ambulance settings to reverse opiate overdose. It is kept on hand in operating rooms to counteract unintended affects of surgical anesthesia. Hospital labor and delivery units keep naloxone taped to every bedside as a safety precaution for instances in which the opiate pain medications given to laboring mothers cause respiratory depression in infants when they are born.
Because most overdoses take place outside of hospitals, community organizations have been distributing naloxone to drug users, their families and loved ones since the mid ‘90s. They've recorded over 53,000 trainings and more than 10,000 successful overdose reversals, according to a 2010 CDC report. There are currently over 188 overdose prevention education centers distributing naloxone in the U.S.
3. Community-based naloxone training may lead to decreased drug use.
The push toward wider public availability of naloxone has not been without controversy. Those who oppose naloxone distribution cite concerns that having ready access to this overdose reversal agent will give drug users an omnipotent, false sense of safety in using drugs and will only encourage increased drug use.
Those who have been administered naloxone in the midst of an overdose tell a much different story.
The action of naloxone is so quick and thorough, that not only does it reverse an opiate overdose, for those addicted to opiates it also precipitates acute withdrawal symptoms. The overdose victim who has received naloxone may spring from unconsciousness to full-on, acute withdraw. Naloxone recipients describe this experience as incredibly frightening and painful, and something to be avoided at all costs; as opposed to a safety net that encourages increased drug use.
Supporters of increased naloxone distribution counter opponents’ concerns that community access to naloxone may increase drug use by emphasizing that naloxone saves lives and offers those struggling with opiate addiction a chance at recovery, regardless of their current drug use.
Opponents equate naloxone distribution with enabling an addict, while supporters question, is it "enabling" to save lives?
Researchers have found that naloxone distribution may actually result in decreased drug use. A study on a pilot naloxone distribution program in San Francisco, published in the Journal of Urban Health in 2005, found decreased heroin use among participants. Study authors cited that the training program was empowering, and that this perhaps decreased hopelessness and increased self efficacy for participants, leading to a decrease in drug use despite the availability of a safety net.
Another study conducted from 2006 to 2008 in Los Angeles’ Skid Row area and published in the International Journal of Drug Policy in 2010 reported similar findings, with 53 percent of participants in a naloxone distribution program decreasing their drug use.
Both studies also reported an increase in participants seeking treatment for their drug use.
4. Naloxone is supplied in various forms, with new forms still in development.
Injectable naloxone is the most widely known form, and it has been to have been used by hospitals, ambulances and community organizations for decades. For people uncomfortable administering naloxone with a needle, many community based overdose prevention centers also distribute naloxone for nasal use.
The nasal form currently distributed is in the same formulation as injectable naloxone, only in a different dosage. The use of naloxone nasally is considered an off-label use by the FDA. Physicians safely prescribe many medications, across all areas of medicine, for off-label use such as this.
Another, more advanced formulation of nasal naloxone is in its final round of clinical trials at the University of Kentucky and has been given fast-track approval by the FDA.
Daniel Wermeling, professor of pharmacy at University of Kentucky, has partnered his startup business, AntiOp, with Reckitt Benckiser Pharmaceuticals to produce and market this new formulation. Contained in a small nasal device, this formulation of naloxone uses a unit dose metered pump. This pump allows a more concentrated form of standard dose naloxone to be distributed in a fine spray mist, enhancing naloxone’s distribution and absorption by the nasal tissue.
The FDA also recently approved Evzio, a standard form of injectable naloxone encased in a small device that verbally guides a user through the process of administering the drug. Evzio is similar in design to other emergency medical devices such as the automated defibrillator and the epi-pen auto injector.
5. Overdose risk can be predicted and mitigated.
There are certain scenarios that create an especially high overdose risk for people who use opioids. The elderly and the cognitively impaired are at high risk of overdose, as confusion may result in multiple doses of medication being consumed in a short period of time. Also, chronic pain patients who take several forms of opiates are at risk, especially when taking newly prescribed medications.
For those addicted to either prescription or illicit opiates, overdose risk is extremely high after even a short period of abstinence from these drugs. Many opiate overdoses occur within hours or days of drug users being released from treatment centers or incarceration.
Educating patients and inmates on overdose prevention and ensuring they have access to naloxone can help mitigate these risks. Overdose prevention should be a key component in the education provided by physicians to their patients each time an opiate is prescribed. Treatment centers must modify their discharge planning to include overdose prevention education for any patient at risk of opiate overdose. Prison and jail inmates at risk of overdose should receive education on overdose prevention prior to release as well.
Currently, overdose prevention education is practically non-existent within our healthcare systems, treatment facilities and jails. It remains to be seen if the public attention overdose is currently receiving will prompt a much needed trend toward education within the systems that serve those who use opiates.
One community based program is taking action where it can. Along with many other services, the DOPE Project (Drug Overdose Prevention and Education), based in San Francisco, conducts overdose prevention workshops for jail inmates preparing to be released. Inmates are shown a video called “Staying Alive on the Outside” in which former inmates describe their experiences with overdose and provide education on overdose prevention and treatment. Once trained, inmates can choose to receive naloxone upon release from jail.
6. State laws regarding overdose prevention and naloxone are rapidly changing.
In March, U.S. Attorney General Eric Holder spoke on the overdose epidemic, naming heroin and opiate overdose an “urgent public health crisis” and calling for widespread first responder access to naloxone. Governor Deval Patrick of Massachusetts declared a public health emergency in his state and Peter Shumlin, governor of Vermont, devoted his entire state of the state address to the growing scourge of opiate and heroin addiction and resultant overdose deaths.
“The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards…while we fear and fight treatment facilities in our backyards,” said Gov. Shumlin. “We must bolster our current approach to addiction with more common sense. We must address it as a public health crisis, providing treatment and support, rather than simply doling out punishment, claiming victory, and moving onto our next conviction.”
To hear an elected official speak so passionately and knowledgeably on the issue of addiction brings a great deal of hope to traumatized families who are desperate for solutions.
Many other states are also responding to the overdose crisis with legislation to increase the distribution of naloxone and “Good Samaritan” acts to protect those who contact emergency services in cases of overdose from prosecution for the possession of small amounts of drugs.
As of February, 26 states have some type of naloxone access law in place, 22 of which allow for third-party administration of naloxone. Third-party prescriptions allow the families and loved ones of those at risk to obtain naloxone and to administer it in the event of an overdose.
Seventeen states have Good Samaritan laws in place and several other states are currently considering similar legislation.
States are also forming programs to allow naloxone to be distributed by pharmacies without the need for a prescription. On September 16, California joined three other states, including New Mexico, Rhode Island and Washington, in enacting legislation to allow pharmacies to furnish naloxone to consumers. New York and Vermont are in the process of drafting similar legislation.
7. A continued overdose epidemic is preventable.
It is alarming that the death rate has grown at such a rapid pace for a condition that is not only treatable, but also preventable. Increased public awareness and education with accurate information regarding overdose risk can prevent these often fatal events from occurring in the first place. And wider availability of naloxone can help save lives when overdose does occur.
Years of research on community-based naloxone distribution show that it can be administered safely and effectively by laypersons and that it does not precipitate increased drug use. Even if it did, the rational question is, “Should the possibility of increased drug use become a deterrent to saving a life?’